Health inspection·April 22, 2025

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the appropriate care and services for one (1) of two (2) sampled residents (Resident 1) who was admitted with indwelling catheter (a tube that helps drain urine from the bladder [organ inside the body that stores urine] through a drainage tube [indwelling catheter tube] into a drainage collection bag) by failing to monitor Resident 1 for signs and symptoms of urinary tract infection (UTI, an infection in the bladder/urinary tract) in accordance with the care plan and facility policy on catheter care. This deficient practice had the potential to result in the delay of treatment and care in the event Resident 1 develops a catheter associated urinary tract infection (germs enter the urinary tract through the urinary catheter and cause infection) which could result in harm, hospitalization, and death. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses which included urine retention (a condition in which you cannot empty all the urine from your bladder), hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) on the right side, and muscle weakness. During a review of Resident 1's Minimum Data Set (MDS, resident assessment tool), dated 1/31/2025, the MDS indicated Resident 1 had intact cognitive skills (ability to think, understand, and reason) for daily decision making. The MDS indicated Resident 1 dependent (helper does all of the effort, resident does none of the effort to complete the activity) in toileting hygiene, lower body dressing, and putting on/ taking off footwear. The MDS also indicated Resident 1 needed substantial/ maximal assistance (helper does more than half the effort. helper lifts, holds trunk or limbs, and provides more than half the effort) in shower/ bathe self, upper body dressing, roll left and right, sit to lying, lying to sitting on side of the bed and tub/ shower transfer. The MDS indicated Resident 1 was admitted to the facility with Indwelling catheter. During a review of Resident 1's the Physician's Order (PO), dated 1/28/2025, the PO indicated indwelling catheter: Foley catheter (type of urinary indwelling catheter) Size: 16 French unit (Fr, a unit of measurement for the catheter's diameter) Balloon Size: 10 cubic centimeters (cc- unit of measurement). Change for blockage leaking, pulled out, excessive sedimentation. Change catheter drainage bag as needed and with every change of indwelling catheter, as needed for urinary retention. During a review of Resident 1's Care Plan (CP) for Indwelling Catheter due to urinary retention and (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 055153 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055153 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montebello Care Center 1035 W Beverly Blvd Montebello, CA 90640 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)